Guiding Factors

Among the factors that clinicians should consider when selecting therapy for patients with relapsed myeloma are their prior therapies or any maintenance therapies. If a previous therapy successfully controlled the disease with a partial response of at least 6 months, that therapy could be considered for reuse. In contrast, if a patient relapsed while on maintenance therapy, a new treatment regimen should not contain that therapeutic agent.1

Clinicians should also consider patient frailty and comorbidities such as neuropathy, infections, or the presence of kidney disease. For example, generally if someone had pre-existing neuropathy, it is best to keep that individual away from a bortezomib-containing regimen, Dr Mikhael said.

A patient’s risk category may also play a role in treatment decisions. According to Dr Mikhael, approximately 25% of patients are classified as having higher-risk disease. In these patients, it might be best to treat more aggressively, trying to get the disease down to its lowest level, to a point where there is no measurable disease. Whereas in patients with standard-risk disease, the condition can be treated more slowly and not as aggressively if the patient is responding, he said.

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“More often than not, the key differentiators for treatment are patient choice and convenience,” Dr Mikhael said. “The patient may want an oral regimen or an IV regimen. We have to find what fits with their lifestyle.”

Developing Guidelines

For physicians looking for greater guidance on how to select the appropriate treatment for patients with relapsed disease, there are few available resources, Dr Mikhael admitted.

“There isn’t a clear consensus,” he said. “The [National Comprehensive Cancer Network] guideline provides some guidance, but is essentially a laundry list of what is available.”

However, Dr Mikhael noted that he is currently leading an effort at the American Society of Clinical Oncology (ASCO) to write a clinical practice guideline for the treatment of multiple myeloma.

“We have been working on it for several months and are hoping to launch it at some point this fall,” Dr Mikhael said. “The goal of the guideline will be to provide practical advice as to how decisions are made for these patients now that there are so many choices.”

References

  1. Laubach JP, van de Donk N, Davies FE, et al. Practical considerations for antibodies in myeloma. Am Soc Clin Oncol Educ Book. 2018;38:667-674. doi: 10.1200/EDBK_205443
  2. Daratumumab (DARZALEX) [press release]. Silver Spring, MD: US Food and Drug Administration; Updated November 22, 2016. https://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm530249.htm. Accessed July 16, 2018.
  3. Elotuzumab [press release]. Silver Spring, MD: US Food and Drug Administration; Updated November 30, 2015. http://wayback.archive-it.org/7993/20170111231612/http://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm474719.htm. Accessed July 16, 2018.
  4. Ixazomib [press release]. Silver Spring, MD: US Food and Drug Administration; Updated November 20, 2015. http://wayback.archive-it.org/7993/20170111231617/http://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm473804.htm. Accessed July 16, 2018.
  5. Daratumumab injection [press release]. Silver Spring, MD: US Food and Drug Administration; Updated November 16, 2015. http://wayback.archive-it.org/7993/20170111231618/http://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm472904.htm. Accessed July 16, 2018.
  6. Carfilzomib/Kyprolis [press release]. Silver Spring, MD: US Food and Drug Administration; Updated July 24, 2015. http://wayback.archive-it.org/7993/20170111231632/http://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm455873.htm. Accessed July 16, 2018.